Imaging findings of congenital heart diseases in CXR

Chest radiography (CXR) continues to play a pivotal role in the preliminary evaluation of congenital heart disease (CHD), especially in settings where advanced imaging modalities may not be readily available. Although not diagnostic on its own, CXR provides essential information regarding cardiac size, shape, and pulmonary vascularity, offering valuable clues that can guide further diagnostic workup. Various congenital cardiac anomalies present with characteristic radiographic features. For example, tetralogy of Fallot may present with a "boot-shaped" heart due to right ventricular hypertrophy and an upturned apex, while transposition of the great arteries typically shows an "egg-on-a-string" appearance due to a narrow superior mediastinum. Similarly, total anomalous pulmonary venous return can manifest as a "snowman" or "figure-of-eight" sign on frontal chest radiographs. Pulmonary vascular markings on CXR can help differentiate between left-to-right shunt lesions (e.g., ventricular septal defect, atrial septal defect, and patent ductus arteriosus), which show increased pulmonary blood flow, and cyanotic lesions with reduced pulmonary flow (e.g., pulmonary atresia, tricuspid atresia). Cardiomegaly is a common finding in many forms of CHD and may reflect volume or pressure overload in specific cardiac chambers. Moreover, associated findings such as rib notching in coarctation of the aorta or prominent pulmonary arteries in Eisenmenger syndrome may provide additional diagnostic clues. While echocardiography and cross-sectional imaging techniques like cardiac MRI and CT angiography offer detailed anatomical insights, the chest X-ray remains a valuable screening and monitoring tool in both pediatric patients with CHD. It assists in assessing disease progression, complications, and response to surgical or medical interventions. Recognizing classic and subtle radiographic patterns is essential for clinicians and radiologists to ensure timely diagnosis and appropriate management of congenital heart diseases.